Oregon Computer May Decide Which Poor Live Or Die

Decide how you would divvy up the money if you had control of a state`s Medicaid budget and you didn`t have enough money to pay for all the health care that all of the poor and low-income folks need.

You could reduce the number of people who get Medicaid by lowering the income level for eligibility. But that would cut many medically indigent people off from health care or force hospitals to treat them free, shifting their costs to other patients and raising the bills for Medicaid and privately insured people.

Essentially, that`s what many states do.

You could put ceilings on how much the state will pay hospitals and doctors for treating Medicaid patients. But then hospitals will push patients out faster and many doctors will refuse to treat them.

Many states do that, too.

You could effectively-without admitting it-ration health care by making it hard for poor folks to get to public clinics and hospitals, by tolerating long waits for attention and generally allowing it to be such a hassle many people just give up.

That`s nothing new.

Or, you could try Oregon`s idea: ration health care by listing all medical procedures in order of their cost-effectiveness and, starting at the bottom, eliminating enough of them to balance your budget.

The Oregon Health Services Commission went public last week with what is essentially a hit list of medical procedures to use in deciding where the state`s Medicaid money is to go. The tabulation contains 1,600 medical procedures, ranked by computer according to a formula that is supposed to balance their costs by how much how many people could be expected to benefit. The calculations include the care and treatment necessary (such as office visit, antibiotics, surgery, chemotherapy), estimated cost, number of years patients can expect to survive (those with measles or pneumonia are usually children and live an average of 69 years afterwards, while the life expectancy of an AIDS patient with pneumonia is put at 5 years) and the ``quality of well-being`` thereafter.

These factors are crunched together by computer to make a ratio that-supposedly-can be used to rank medical procedures by their cost-

effectiveness.

Later this year, the Oregon legislature is supposed to draw a line on the list, with Medicaid paying for the procedures above it and not those below.

But apparently even the computer balked at the idea. Much of what it spit out in a new 167-page report is incomplete and inaccurate. Many of the descriptions of care are gross underestimates, so the costs of many treatments are wrong, as are the other calculations that follow.

In theory, there are many justificiations for the Oregon law. It is intended to provide basic health care for all those who can`t afford it, greatly expanding the number of poor and working-poor people eligible for Medicaid coverage.

The Oregon plan also stresses preventive care over high-cost, high-tech procedures. For example, it assumes it would be more cost-effective to spend money on prenatal care for a hundred women or immunize 2,000 children than pay for a single, risky heart-lung transplant.

Drawing the hard lines that will inevitably condemn some people to death because their medical care falls below the cut-off point on the cost-effectiveness list isn`t so bad when it`s only statistics and computers. But eventually these will be real people who will go without help, people who will tell their stories to newspaper reporters and TV cameras, people whose families will pressure politicians.

The pressures for some kind of rationing may seem inexorable. Medical costs have long been out of control. Health spending jumped 10.4 percent in 1988, according to a report just put out by the Department of Health and Human Services. The bills average out to $2,124 per person, twice as much as in 1980. The total came to $539.9 billion, twice the tab in 1980, and 11.1 percent of the gross national product-up from 9.1 percent in 1980, 7.3 percent in 1970 and 5.3 percent in 1960.

The Oregon effort-assuming it can get its list of priorities in order-will be watched closely by other states, health insurers and employers to see whether it can effectively hold the line on Medicaid costs without setting off an uproar of protest.

The odds are against it. Health care costs are unrelenting. People deliberately deprived of life-saving care by a computer and a faceless state can easily become irresistible media stories. Complex cost shifting, third-party payers and other political/economic subterfuges will dull the financial pain of health care costs for most of us enough to make the Oregon experiment seem too hard-hearted to copy. I bet you`d decide to raise taxes instead.